Skin breaks, abrasion, blister, or shallow crater, edema, and infection are characteristics of

Correct Answer: B

Rationale: Stage II pressure ulcers involve partial-thickness skin loss, presenting as abrasions, blisters, or shallow craters, often with edema or infection if untreated. Stage I shows non-blanchable redness, Stage III extends to subcutaneous tissue, and Stage IV reaches muscle or bone. Nurses assess these signs to stage ulcers accurately, guiding interventions like pressure relief or wound care, preventing progression and promoting healing in at-risk patients.

Correct Answer: D

Rationale: Effective charting requires accuracy, clarity, and accountability, adhering to legal and professional standards. Signing the medication sheet after administering medication, as Nurse Jane does, exemplifies this by confirming the intervention occurred, ensuring patient safety, and providing a verifiable record. This practice aligns with the 'Five Rights' of medication administration and reduces error risks, such as double-dosing. Conversely, signing as 'J.R.' lacks full identification (name and title), compromising accountability. Using a pencil risks erasure or alteration, undermining record integrity, as permanent ink is standard. Noting 'appetite is good' is subjective and lacks detail (e.g., meal percentage consumed), reducing its clinical value. Nurse Jane's action of signing post-medication administration reflects a strong grasp of charting's role in care continuity and safety, making it the best demonstration of effective documentation principles.

Correct Answer: D

Rationale: Prescriptive theories in nursing specify actions for specific situations, reflecting practice and addressing phenomena like pain management with concrete interventions (e.g., administer analgesics). Unlike descriptive theories, which only describe (e.g., pain's nature), or explanatory ones, which explain and predict (e.g., why pain occurs), prescriptive theories guide what nurses should do, offering practical direction. Explaining, relating, and predicting fit mid-range or grand theories, not prescriptive ones' narrow focus. Providing a broad framework suits grand theories (e.g., Orem's), not prescriptive specificity. Reflecting practice and addressing phenomena captures prescriptive theories' role bridging theory to actionable care, like protocols for patient symptoms, making this the most precise definition in nursing theory application.

Correct Answer: A

Rationale: Critical thinking directs assessment purposefully e.g., probing fatigue to link it to anemia ensuring data collection is focused and relevant. This active process analyzes, synthesizes, and prioritizes, enhancing care planning. Reviewing with providers follows assessment, not its direction. Determining care is planning/implementation, not assessment's role. Identifying responses fits evaluation, not initial data-gathering. Critical thinking's role in steering assessment ensures efficiency and depth, making it the key way nurses apply this cognitive skill in practice.

Correct Answer: C

Rationale: Spreading feet apart creates a wide base of support, stabilizing the nurse's center of gravity when lifting a client from bed to chair. This enhances balance, reducing fall risk e.g., shoulder-width stance supports a 70-kg patient. Bending at the waist risks back strain, lacking leg leverage, and no base is specified. Facing the client, bending knees, and holding forearms uses proper mechanics but omits base width less explicit. Tightening pelvic muscles aids core strength, not base stability. A wide stance, per ergonomic principles, ensures safe transfer, protecting nurse and client, making it the essential action in this context.